Part 1

Part 1: Case Study

Mary Jones picture

You are in clinic and your next patient is Ms. Mary Jones. Both Mary and her mother have been your patients for several years and you see typically see Mary once a year for a routine annual exam. Mary is an independent young woman (aged 32). The eldest child of an alcoholic father, who died when she was 15, and a mother who, though loving, was inclined to depression. Mary had learned to stand on her own feet from an early age and had helped to bring up her younger siblings. She married at 22 to David, a bright young architect, and they had two daughters aged 2 and 5. Mary was an exemplary mother, so much so that David felt somewhat neglected and the tensions between did not improve when, six months ago, he had a small intestinal bleed and was found to have extensive spread of an abdominal cancer. Despite this, his general condition remained good throughout subsequent radiotherapy and chemotherapy.

He was admitted to the hospice in order to give his wife a rest, but suffered a sudden hematemesis during a visit, covering Mary with blood and scaring their two young children. Sadly, the bleeding could not be stemmed and he died a day later.

Mary’s immediate concern was for her two children. She behaved with admirable fortitude, calling on her mother to stay while she dealt efficiently with the many practical matters arising from David’s death.

You see Mary a week after David’s death and refer her to a bereavement service. When seen by the bereavement service organizer she said she was “fine”, denied being depressed and would not think of suicide “for the sake of the children”.



An experienced volunteer counselor was assigned and phoned Mary a week later in the hope of setting up a visit. Mary answered the phone and said that she had a house full of people and was far too busy to see the volunteer. On the phone she sounded tense and brittle.


The volunteer phoned a week later by which time Mary was keen to talk and accepted the offer of a visit the following day “For the sake of the children”. At that visit Mary said she was too busy to think about the past but was sleeping badly and suffering recurrent nightmares in which David reached out to her. When she responded he vomited blood in her face, she then woke up in great distress.

The volunteer met Mary’s mother, who said she was coping well but seemed depressed. The youngest child was said to be crying a lot and the older had been wetting the bed.


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